It's Not Just About Survival: Why Some Breast Cancer Patients Opt For Surgery on Both Sides

Years ago, journalists who had breast cancer fought with words to inform other women with breast cancer that, in many cases, they didn’t need a mastectomy. Lumpectomy is sufficient, they pointed out. In 1990, the NIH published a consensus statement emphasizing the fact that for most women with small tumors, there is no survival benefit in lopping of the full breast.

For a while, rates of mastectomy declined. Surgeons and oncologists were trained to encourage patients with early-stage breast cancer to have smaller procedures, and many did. Now, single-sided mastectomy rates among women with breast cancer remain lower, reflecting that a greater proportion of women with small tumors choose lumpectomy.

What’s up - and trending for over a decade now – are double and prophylactic mastectomies. A mastectomy epidemic, as some call it, may be attributed in part to genetic testing, fear of the developing the disease among women at greater risk, and advances in reconstructive surgery.

A recent article in the JNCI focuses on prophylactic contralateral mastectomy (CPM) in women with a tumor on one side and lack a known genetic disposition to breast cancer. The researchers used computer models to demonstrate that for someone with a stage 1 or 2 invasive cancer who has a mastectomy, taking the breast off the other side doesn’t significantly change their likelihood of living longer or not dying from breast cancer.

The survival benefit, after years and years of follow-up, remains under 1 percent. So why might a reasonable woman with a small breast tumor choose a double mastectomy?

First, it’s not a simple decision. Many factors weigh in. And unfortunately often, the choice is made in a hurried or panicky response to a malignant diagnosis. There is no doubt that in the overwhelming majority of early-stage breast cancer cases, lumpectomy is enough surgery for cure or long-term remission. (Where the data are more complicated has to do with what treatment to give after surgery – if radiation is really necessary besides chemotherapy, along with hormonal treatment, etc.)

Second, this discussion has nothing to do with Angelina Jolie, although her case is sometimes cited as a factor in decisions for bilateral surgery. She chose to have bilateral prophylactic surgery because she carries a strong inherited disposition for developing breast cancer. The JNCI study excludes women with known BRCA mutations. And while many U.S. women with breast cancer are assured coverage for reconstructive breast surgery, few women have access to such talented plastic surgeons as does the actress.

Reality: many women I knew when I was practicing oncology, and subsequently whom I know as a peer patients, are flat-out disappointed by the cosmetic results obtained after breast reconstruction. It’s not a boob job.